The New York University Division of Nursing (NYU-DON) and the Center for Home Care Policy and Research (CHCPR) at the Visiting Nurse Service of New York (VNSNY) propose to establish a Developmental Center for Evaluation and Research in Patient Safety (DCERPS). The DCERPS will focus on health care provided in the home setting, particularly on care provided by nurses, and its relationship to patient safety in home care. Home care is a significant sector of the health care system that has received little attention, even though patient adverse events resulting from medical errors have been a focus of heightened professional, public, and Congressional (GAO, 2000) concern, especially since publication of the Institute of Medicine's report To Err is Human. In recent years, physician-related errors and patient injuries occurring in hospitals and nursing homes have been the most widely studies, whole less is known about errors in non-institutional settings. The goal of the NYU-VNSNY DCERPS is to establish an ongoing center that can provide the intellectual resources and disciplinary skills, the measurement tools and the organizational techniques for understanding medical errors in home health care and designing and evaluating mechanisms for learning from such errors and reducing them. Over the net three years (Phases 1 and 2 of the project) our goals and to 1) develop a multi-disciplinary team to conduct research on patient safety, 2) strengthen the ties between NYU-DON and VNSNY, 3) develop educational programs on the importance of patient safety and evidence- based approaches to improving it, and 4) conduct research pilot studies. The DCERPS will mobilize resources from both institutions, as well as selected outside consultants, and will include a multi-disciplinary team of registered nurses (RNs), physicians, social scientists, statisticians, and epidemiologists, and management experts. The prime focus of our work will be care provided to older adults and minority groups in inner-city areas. Unlike many home health agencies, VNSNY has a large non-white population. Approximately two-thirds of the patients served by VNSNY are 65 or older, while about 3 out of 10 are black and 2 out of 10 are Hispanic.